“I found out about my 'abnormal mammogram' through a voicemail and couldn't speak to my general practitioner until three days later. Then I had to wait four weeks for a biopsy and to finally see a surgeon. During that time, I lost almost 10 pounds due to agonizing anxiety.”
Ellyn Winters-Robinson – breast cancer survivor
While our arsenal of weapons to battle breast cancer is constantly increasing, and clinicians are now better than ever equipped to cure the disease, new challenges arise. Along with the necessity of eliminating treatment-related toxicity and resolving the financial distress caused by cancer, there is a great need to reduce time toxicity.
Patient anxiety during their cancer journey often leads to fatigue, trouble sleeping, and depression. This complicates diagnostic and therapeutic procedures, reduces adherence to recommendations, and negatively impacts communication and overall well-being. Numerous studies have shown that stress can not only contribute to cancer initiation and impair treatment effectiveness but can also promote cancer growth and the development of metastases1. To achieve better overall outcomes in oncology, it is imperative to identify additional sources of stress in cancer patients and address them effectively.
We want to reduce the time during which patients experience unavoidable anxiety
We broadly refer to this as reducing time toxicity in oncology care by mitigating the negative impact on a patient's quality of life caused by the time demands associated with cancer detection, diagnosis, treatment, and recovery. Time toxicity affects patients' daily routines, employment, social interactions, emotional well-being, and may also have financial implications. It is a significant contributor to frustration, anxiety, and stress2.
To ensure timely and appropriate care, quality of care standards, including timing requirements for breast cancer treatment, are often established, and sometimes enforced by national health authorities and professional organizations. Guidelines generally include specific, mandatory timelines that healthcare providers are expected to follow, with a primary focus on time-to-treatment metrics. And these standards can vary significantly by country or issuing institution.
However, breast cancer care is complex, and even within the context of “time-to-treatment”, many factors can contribute to delays, such as scheduling appointments, patient navigation, and data management. While it may be challenging to assess the relative burden of time toxicity at different stages of cancer care, there is strong evidence supporting the need to improve time to diagnosis.
Time to diagnosis in breast cancer care is the interval between when a patient first presents with symptoms or an abnormal screening result (such as a suspicious mammogram, for example) and the confirmation of a breast cancer diagnosis through a biopsy or other diagnostic tests
Keeping in mind that tumor doubling time in breast cancer (an indicator of disease progression), can be as short as 25 days, this can result in the transition from a Stage 1 to Stage 2 cancer potentially occurring within just a few months3. Shortening the time to diagnosis and the corresponding time to treatment initiation is critical for the overall prognosis and outcomes in cancer care for the patient.
The level of stress experienced by breast cancer patients varies individually throughout their care journey, but research and clinical observations suggest that certain key moments are associated with higher levels of stress4. Notably, women with suspected breast cancer experience greater anxiety during the diagnostic period than those with an established diagnosis. For example, stress levels are significantly higher when patients are notified about a breast biopsy and during the wait before the biopsy, compared to after receiving the biopsy results5.
Data from 419 centers covering 1,805,515 U.S. patients submitted to The National Quality Measures for Breast Centers between 2005 and 2019 indicates that the average time from a screening mammogram to a biopsy procedure was 13 business days, with a maximum time of 26 business days6. When factoring in the pathology report turnaround time and scheduling a follow-up appointment, the total delay to diagnosis for a women can extend to over a month. It is not surprising that the emotional and mental toll of waiting, resulting from dissatisfaction with the timelines for various parts of the diagnostic process, is among the top patient-reported concerns regarding the timeliness of breast cancer procedures7.
Breast cancer care is multidisciplinary, with patients often interacting with multiple doctors and specialists across different locations. While individual departments may perform well in terms of their part and turnaround times, cumulative delays across the entire care pathway can still be significant. Therefore, professional coordination of care is essential to minimizing these delays.
And during the detection and diagnosis phase of breast cancer, where it is already not possible to prevent the disease, reducing the patient's stress and setting a solid foundation for better overall outcomes can be achieved by reaching a definitive answer as quickly as possible. This approach is the first step in addressing time toxicity, which is essential for improving the overall experience with care for breast cancer patients and ensuring that the benefits of treatment are not overshadowed by the burden of time.
For more information, read the white paper: Revolutionizing Breast Cancer Diagnosis
References:
- Eckerling, A., Ricon-Becker, I., Sorski, L. et al. Stress and cancer: mechanisms, significance and future directions. Nat Rev Cancer 21, 767–785 (2021)
- Adjustment to Cancer: Anxiety and Distress – Patient Version by NIH National Cancer Institute (https://www.cancer.gov/about-cancer/coping/feelings/anxiety-distress-pdq)
- L Heuser, J S Spratt Jr, H C Polk Jr, J Buchanan. Relation between mammary cancer growth kinetics and the intervals between screenings. Cancer. 1979 Mar;43(3):857-62
- Liu Y, Tian S, Ning B, Huang T, Li Y and Wei Y. Stress and cancer: The mechanisms of immune dysregulation and management. Front. Immunol. 13:1032294 (2022)
- Liao, Mei-Nan MSN; et al. Uncertainty and anxiety during the diagnostic period for women with suspected breast cancer. Cancer Nursing 31(4) (2008)
- Cory Amanda Donovan, Cary S. Kaufman, Kari A. Thomas et al. Timeliness of Breast Diagnostic Imaging and Biopsy in Practice: 15 Years of Collecting, Comparing, and Defning Quality Breast Cancer Care. Ann Surg Oncol (2023) 30:6070–6078
- Marie L. Feferman, Tammy K. Stump, Danielle Thompson, et al. Patient‑reported observations on medical procedure timeliness (PROMPT) in breast cancer: a qualitative study. Breast Cancer Res Treat 2024 Jul 4
